Program Operations Manual System (POMS)

HI 00601.125 SNF Coverage Guidelines

In any discussion about SNF services, it is most important not to create the impression that a beneficiary is entitled to 100 benefit days “automatically.”

Explain the requirements for coverage of an SNF stay. In addition, make it clear that the DO can supply only general information, and that whether an SNF stay is covered is a decision which the intermediary makes based on the facts which are furnished by the physician, the hospital and the SNF.

If a beneficiary asks whether a contemplated SNF stay will be covered, supply the information in A. above. In addition, explain that Medicare coverage is determined by the intermediary and depends upon the level of care needed and received by the beneficiary. The coverage determination can be made only after the beneficiary has been admitted to the SNF and the intermediary has received a claim for services and medical data furnished by the SNF concerning the care required by the beneficiary.

The beneficiary may be informed by the SNF that his stay is noncovered and he may desire to file an appeal before he receives the disallowance notice. In this case, see GN 03101.070. The beneficiary may also be informed that part of his stay was covered but that as of a certain date, the coverage was terminated.

Provide the inquirer with the basic information as to what constitutes covered services. It should be remembered that a physician may appropriately recommend a patient's stay in an SNF without knowing whether Medicare will pay for the care provided. A physician's decision may be influenced by social and other factors including the unavailability of friends or relatives to care for the patient at home. While such considerations are appropriate for the physician, they do not affect the intermediary's coverage determination.

If the entire SNF stay has been denied after a considerable period of time has elapsed since the date of admission, explain to the beneficiary that generally, the intermediary can make a determination on the claim only after it has been received and evaluated. Do not give the impression that either the provider or the intermediary is at fault when a retroactive denial is made.

If the beneficiary indicates that he is dissatisfied with the explanation, assist him in filing a request for reconsideration.

The waiver of liability provision applies to SNF admissions when the beneficiary (or the provider) did not know, and had no reason to know that the care was not medically necessary or reasonable or constituted custodial care.